Bulimia nervosa (BN) is a prevalent form of psychopathology among late adolescent and young adult women. The disorder is associated with significant adverse medical and psychosocial sequelae. Although manual based psychotherapies for BN have been developed and a standard-of-care for these patients has emerged, most practicing psychotherapists who treat individuals with BN have not been adequately trained to deliver such therapies. Therefore, there appears to be a growing discrepancy between what is being used experimentally in academic centers and recommended by researchers in the field (e.g., cognitive behavioral therapy (CBT)), and what is actually available in the community. Although this deficiency might be remedied through the development of training programs to improve therapists skills in this area, such programs would be difficult to administer logistically, and it is unlikely that most practitioners would have the time or financial resources to undertake such training. Also, the skills obtained might atrophy over time if a sufficient number of cases were not seen. Another model to deliver such therapy would be to have trained therapists travel to these areas, although given current reimbursement guidelines such an approach would probably not be self-supporting. Another option is telemedicine delivered therapy. We have recently finished a randomized trial comparing CBT delivered via telemedicine to CBT delivered in person in rural and smaller urban areas in North Dakota and northwestern Minnesota. The two treatments were equally effective and acceptable to patients, with good maintenance of treatment effects at 1-year follow-up. We were also part of a recent multi-center trial comparing CBT to a stepped-care model, wherein subjects received self-help CBT, followed by fluoxetine if still symptomatic, and then followed by full CBT if they were still symptomatic after the first two interventions. The stepped-care model was more cost effective than initial CBT in terms of subjects achieving abstinence and the self-help followed by CBT sequence seemed to act synergestically, engendering the best outcome. Incorporating the above findings, we would now like to extend this line of research to compare CBT delivered via telemedicine to supervised self-help CBT also delivered via telemedicine to unsupervised self-help. This additional study would allow us to pursue our goal of developing delivery systems for effective and cost-effective intervention for patients in rural areas, where specialized treatments are usually not available. Subjects would be recruited in various areas in North Dakota and randomly assigned to 20 sessions of CBT or 8 brief sessions of supervised self-help, over 16 weeks, both delivered via telemedicine, or to unsupervised self-help. Nonresponders in both self-help cells would then receive CBT via telemedicine. Subjects would be reevaluated at the end of each intervention and at follow-up. [unreadable] [unreadable] [unreadable] [unreadable]